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Mafi VIP, Soldera J. Palliative care for end-stage liver disease and acute on chronic liver failure: A systematic review. World J Methodol 2024; 14:95904. [DOI: 10.5662/wjm.v14.i4.95904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 06/20/2024] [Accepted: 07/03/2024] [Indexed: 07/26/2024] Open
Abstract
BACKGROUND End stage liver disease (ESLD) represents a growing health concern characterized by elevated morbidity and mortality, particularly among individual ineligible for liver transplantation. The demand for palliative care (PC) is pronounced in patients grappling with ESLD and acute on chronic liver failure (ACLF). Unfortunately, the historical underutilization of PC in ESLD patients, despite their substantial needs and those of their family caregivers, underscores the imperative of seamlessly integrating PC principles into routine healthcare practices across the entire disease spectrum.
AIM To comprehensively investigate the evidence surrounding the benefits of incorporating PC into the comprehensive care plan for individuals confronting ESLD and/or ACLF.
METHODS A systematic search in the Medline (PubMed) database was performed using a predetermined search command, encompassing studies published in English without any restrictions on the publication date. Subsequently, the retrieved studies were manually examined. Simple descriptive analyses were employed to summarize the results.
RESULTS The search strategies yielded 721 references. Following the final analysis, 32 full-length references met the inclusion criteria and were consequently incorporated into the study. Meticulous data extraction from these 32 studies was undertaken, leading to the execution of a comprehensive narrative systematic review. The review found that PC provides significant benefits, reducing symptom burden, depressive symptoms, readmission rates, and hospital stays. Yet, barriers like the appeal of transplants and misconceptions about PC hinder optimal utilization. Integrating PC early, upon the diagnosis of ESLD and ACLF, regardless of transplant eligibility and availability, improves the quality of life for these patients.
CONCLUSION Despite the substantial suffering and poor prognosis associated with ESLD and ACLF, where liver transplantation stands as the only curative treatment, albeit largely inaccessible, PC services have been overtly provided too late in the course of the illness. A comprehensive understanding of PC's pivotal role in treating ESLD and ACLF is crucial for overcoming these barriers, involving healthcare providers, patients, and caregivers.
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Affiliation(s)
- Vakaola I Pulotu Mafi
- Post-Graduate Program, Acute Medicine, University of South Wales, Cardiff CF37 1DL, United Kingdom
| | - Jonathan Soldera
- Post-Graduate Program, Acute Medicine, University of South Wales, Cardiff CF37 1DL, United Kingdom
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Iavarone M, Canova L, Alimenti E, Aghemo A, Taveggia D, Gobber G, Cabibbo G, Veronese S, Calvaruso V, Orsi L, Caraceni P, Lampertico P. Palliative care in patients with hepatocellular carcinoma: Results from a survey among hepatologists and palliative care physicians. Palliat Med 2024; 38:1033-1041. [PMID: 39193728 DOI: 10.1177/02692163241269794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
BACKGROUND Delays and limitations of palliative care in patients with liver transplantation-ineligible end-stage hepatocellular carcinoma according to Barcelona Clinic Liver Cancer staging system may be explained by different perceptions between hepatologists and palliative care physicians in the absence of shared guidelines. AIM To assess physicians' attitudes toward palliative care in end-stage hepatocellular carcinoma and to understand what the obstacles are to more effective management and co-shared between palliative care physicians and hepatologists. DESIGN Members of the Italian Association for the Study of Liver Disease and the Italian Society of Palliative Care were invited to a web-based survey to investigate practical management attitude for patients with liver transplant-ineligible end-stage hepatocellular carcinoma. PARTICIPANTS Physician members of the of the two associations, representing several hospitals and services in the country. RESULTS Ninety-seven hepatologists and 70 palliative care physicians completed the survey: >80% regularly follow 1-19 patients; 58% of hepatologists collaborate with palliative care physicians in the management of patients, 55% of palliative care physicians take care of patients without the aid of hepatologists. Management of cirrhosis differed significantly between the two groups in terms of prescription of albumin, esophagogastroduodenoscopy, anti-viral treatment, anticoagulation, indication to paracentesis and management of encephalopathy. Full-dose acetaminophen is widely used among hepatologists, while opioids are commonly used by both categories, at full dosage, regardless of liver function. CONCLUSIONS This survey highlights significant differences in the approach to patients with liver transplantation-ineligible end-stage hepatocellular carcinoma, reinforcing the need for shared guidelines and further studies on palliative care in the setting.
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Affiliation(s)
- Massimo Iavarone
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, CRC "A. M. and A. Migliavacca" Center for Liver Disease, University of Milan, Milan, Italy
| | - Lorenzo Canova
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Eleonora Alimenti
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Division of Internal Medicine and Hepatology, Humanitas Research Hospital IRCCS, Rozzano, Italy
| | | | - Gino Gobber
- UO Palliative Care, Department of Primary Care, APSS Trento, Italy
| | - Giuseppe Cabibbo
- Gastroenterology & Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | | | - Vincenza Calvaruso
- Gastroenterology & Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Luciano Orsi
- Italian Journal of Palliative Care, Italian Society of Palliative Care, Milan, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Unit of Semeiotics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pietro Lampertico
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, CRC "A. M. and A. Migliavacca" Center for Liver Disease, University of Milan, Milan, Italy
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3
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Nadim MK, Kellum JA, Forni L, Francoz C, Asrani SK, Ostermann M, Allegretti AS, Neyra JA, Olson JC, Piano S, VanWagner LB, Verna EC, Akcan-Arikan A, Angeli P, Belcher JM, Biggins SW, Deep A, Garcia-Tsao G, Genyk YS, Gines P, Kamath PS, Kane-Gill SL, Kaushik M, Lumlertgul N, Macedo E, Maiwall R, Marciano S, Pichler RH, Ronco C, Tandon P, Velez JCQ, Mehta RL, Durand F. Acute kidney injury in patients with cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) joint multidisciplinary consensus meeting. J Hepatol 2024; 81:163-183. [PMID: 38527522 PMCID: PMC11193657 DOI: 10.1016/j.jhep.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 03/27/2024]
Abstract
Patients with cirrhosis are prone to developing acute kidney injury (AKI), a complication associated with a markedly increased in-hospital morbidity and mortality, along with a risk of progression to chronic kidney disease. Whereas patients with cirrhosis are at increased risk of developing any phenotype of AKI, hepatorenal syndrome (HRS), a specific form of AKI (HRS-AKI) in patients with advanced cirrhosis and ascites, carries an especially high mortality risk. Early recognition of HRS-AKI is crucial since administration of splanchnic vasoconstrictors may reverse the AKI and serve as a bridge to liver transplantation, the only curative option. In 2023, a joint meeting of the International Club of Ascites (ICA) and the Acute Disease Quality Initiative (ADQI) was convened to develop new diagnostic criteria for HRS-AKI, to provide graded recommendations for the work-up, management and post-discharge follow-up of patients with cirrhosis and AKI, and to highlight priorities for further research.
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Affiliation(s)
- Mitra K Nadim
- Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lui Forni
- School of Medicine, University of Surrey and Critical Care Unit, Royal Surrey Hospital Guildford UK
| | - Claire Francoz
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, Paris, France
| | | | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, Department of Critical Care, London, UK
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jody C Olson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED, University and Hospital of Padova, Padova, Italy
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Elizabeth C Verna
- Division of Digestive and Liver Diseases, Columbia University, New York, NY, USA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Divisions of Critical Care Medicine and Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, University and Teaching Hospital of Padua, Italy
| | - Justin M Belcher
- Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Scott W Biggins
- Division of Gastroenterology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Akash Deep
- Pediatric Intensive Care Unit, King's College Hospital, London, UK
| | - Guadalupe Garcia-Tsao
- Digestive Diseases Section, Yale University School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Yuri S Genyk
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Division of Abdominal Organ Transplantation at Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Pere Gines
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi-Sunyer and Ciber de Enfermedades Hepàticas y Digestivas, Barcelona, Catalonia, Spain
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Nuttha Lumlertgul
- Excellence Centre in Critical Care Nephrology and Division of Nephrology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Etienne Macedo
- Division of Nephrology, Department of Medicine, University of California San Diego, CA, USA
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Raimund H Pichler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza-Italy
| | - Puneeta Tandon
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Juan-Carlos Q Velez
- Department of Nephrology, Ochsner Health, New Orleans, LA, USA; Ochsner Clinical School, The University of Queensland, Brisbane, QLD, Australia
| | - Ravindra L Mehta
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - François Durand
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, Paris, France; University Paris Cité, Paris, France.
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Ufere NN. Increasing Healthcare System Empathy for Patients with Advanced Liver Disease: My Top 10 Lessons in Palliative Hepatology. Dig Dis Sci 2024; 69:1929-1933. [PMID: 38704486 DOI: 10.1007/s10620-024-08406-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 05/06/2024]
Affiliation(s)
- Nneka N Ufere
- Liver Center, Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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Karvellas CJ, Bajaj JS, Kamath PS, Napolitano L, O'Leary JG, Solà E, Subramanian R, Wong F, Asrani SK. AASLD Practice Guidance on Acute-on-chronic liver failure and the management of critically ill patients with cirrhosis. Hepatology 2024; 79:1463-1502. [PMID: 37939273 DOI: 10.1097/hep.0000000000000671] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Affiliation(s)
- Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Jasmohan S Bajaj
- Virginia Commonwealth University, Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Patrick S Kamath
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | | | - Jacqueline G O'Leary
- Department of Medicine, Dallas Veterans Medical Center, University of Texas Southwestern Medical Center Dallas, Texas, USA
| | - Elsa Solà
- Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford, California, USA
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Petrosyan R, Endres P, Ufere NN, St Hillien SA, Krinsky S, Kalim S, Nigwekar SU, Ouyang T, Allegretti AS. Healthcare Resource Utilization and Goals of Care Discussions in Patients with Cirrhosis and Acute Kidney Injury. Dig Dis Sci 2024; 69:1948-1955. [PMID: 38451428 PMCID: PMC11162308 DOI: 10.1007/s10620-024-08317-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/25/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND Patients with cirrhosis and acute kidney injury (AKI) are critically ill and have high health care resource utilization (HCRU). The impact and timing of goals of care discussions on HCRU are not well described. METHODS 221 patients enrolled in a prospective cohort study of patients admitted with AKI and cirrhosis were reviewed. Documentation and timing of a goals of care discussions were analyzed as predictors of HCRU, defined as a composite outcome of intubation, initiation of renal replacement therapy, and/or admission to the intensive care unit. RESULTS Median MELD score was 26 [IQR 19, 33]. 29% patients were listed for liver transplant. 90-day mortality was 61%. 51% patients had at least one HCRU episode. Code status changed from admission to discharge from 91%/7%/0% to 68%/14%18% (full code/do not resuscitate/comfort measures, p < 0.001). 28% patients underwent goals of care discussions, with change in code status at a median of 16 [9, 22] days into admission. Only 18% of discussions were within 7 days of admission and all were after an HCRU event. Being listed for liver transplant was not associated with whether goals of care discussions occurred (23% listed vs. 31% non-listed, p = 0.24) but was associated with higher HCRU (69% vs. 43%; p < 0.001). CONCLUSION Goals of care discussions occurred late into the hospital course, after episodes of HCRU. Efforts should be made to engage in these discussions earlier in the hospital stay, which may decrease HCRU rates in this critically ill population and align with patients' goals of care.
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Affiliation(s)
- Romela Petrosyan
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA
| | - Paul Endres
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Nneka N Ufere
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Shelsea A St Hillien
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA
| | - Scott Krinsky
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA
| | - Sahir Kalim
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA
| | - Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA
| | - Tianqi Ouyang
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 1008, Boston, MA, 02114, USA.
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Moreno-Loro A, Giráldez Á, Jiménez F, López-Bueno I, Pérez-Ramírez A, Romero-Gómez M. Novel approaches in the medical management of compensated cirrhosis. Expert Rev Gastroenterol Hepatol 2024; 18:239-256. [PMID: 38785070 DOI: 10.1080/17474124.2024.2358149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 05/17/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Classically, clinical practice guidelines and expert recommendations have focused on the management of decompensated cirrhotic patients, so we focused this review on improving care for compensated cirrhotic patients who are followed up in outpatient clinics. AREAS COVERED We reviewed the current methods for establishing liver function, the diagnosis and management of advanced chronic liver disease and clinically significant portal hypertension as well as the prevention of its complications, with special attention to covert hepatic encephalopathy, we also paid attention to the extrahepatic complications of cirrhosis and the palliative care. All this from the perspective of evidence-based medicine and trying to empower precision medicine. The literature search was undertaken by PubMed with 'cirrhosis,' 'advanced chronic liver disease,' 'liver function,' 'portal hypertension,' 'covert hepatic encephalopathy,' 'minimal hepatic encephalopathy,' 'palliative care' as MeSH terms. EXPERT OPINION We must offer compensated cirrhotic patients specific care and measures to prevent the progression of the disease and the appearance of its complications beyond the calculation of liver function and imaging screening for hepatocellular carcinoma that we perform every six months. Entities that have typically received little attention, such as covert hepatic encephalopathy, extrahepatic complications and symptoms of cirrhosis, and palliative care, must come to the spotlight.
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Affiliation(s)
- Antonio Moreno-Loro
- Digestive Diseases Department and ciberehd, Virgen del Rocío University Hospital, Institute of Biomedicine (HUVR/CSIC/US), University of Seville, Seville, Spain
| | - Álvaro Giráldez
- Digestive Diseases Department and ciberehd, Virgen del Rocío University Hospital, Institute of Biomedicine (HUVR/CSIC/US), University of Seville, Seville, Spain
| | - Fernando Jiménez
- Digestive Diseases Department and ciberehd, Virgen del Rocío University Hospital, Institute of Biomedicine (HUVR/CSIC/US), University of Seville, Seville, Spain
| | - Ignacio López-Bueno
- Digestive Diseases Department and ciberehd, Virgen del Rocío University Hospital, Institute of Biomedicine (HUVR/CSIC/US), University of Seville, Seville, Spain
| | - Alberto Pérez-Ramírez
- Digestive Diseases Department and ciberehd, Virgen del Rocío University Hospital, Institute of Biomedicine (HUVR/CSIC/US), University of Seville, Seville, Spain
| | - Manuel Romero-Gómez
- Digestive Diseases Department and ciberehd, Virgen del Rocío University Hospital, Institute of Biomedicine (HUVR/CSIC/US), University of Seville, Seville, Spain
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Tian T, Guo J, Hu JL, Hu Y, Guo P, Yu XY. Advanced hepatocellular carcinoma and palliative care: a scoping review. BMJ Support Palliat Care 2024; 14:163-170. [PMID: 36396345 DOI: 10.1136/spcare-2022-003798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/19/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with advanced hepatocellular carcinoma (HCC) have specific palliative care needs owing to the influence of the disease on abdominal pain, jaundice, bleeding, appetite, ascites, liver function and hepatic encephalopathy. This research would help develop care models and identify knowledge gaps in the field. AIMS To identify the palliative care needs and experiences of patients with advanced HCC. METHODS CINAHL, EMBASE and MEDLINE were used to search English literature from January 1998 to March 2022 for 'Palliative care' and 'Hepatocellular cancer' using precise inclusion and exclusion criteria. RESULTS The retrieves identified 2710 records, including 33 studies used in our research. Two additional studies were grey items. Among 35 studies, 13 studies were performed in Asia, 11 studies in North America, 8 studies in Europe and 3 studies in Australia. Quantitative investigations were mostly descriptive or observational. Eight studies were conducted on a national scale, while two were in specific regions. 20 studies were conducted by a single institution. 22 studies focused only on patients, 2 on family caregivers and 2 on healthcare professionals. 2 more studies concentrated on patients and family caregivers, while 6 concentrated on patients and healthcare professionals. CONCLUSIONS This scoping study illustrates the complexity of advanced HCC treatment and challenges in modern healthcare systems. Formulating appropriate referral criteria, integrating and coordinating care, and assessing care contents are crucial. To enhance the treatment of patients with advanced HCC, it is important to understand the relationships between research and service design across teams, disciplines and care settings.
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Affiliation(s)
- Tian Tian
- School of Nursing, Hunan University of Tradtional Chinese Medicine, Changsha, Hunan, China
| | - Ju Guo
- Graduate of School, GuangXi University of Traditional Chinese Medicine, Nanning, Guangxi, China
| | - Ju-Lan Hu
- Department of Rehabilitation, Affiliated Hospital of Jinggangshan University, Ji'An, Jiangxi, China
| | - Yue Hu
- Department of Nursing, Chongqing City Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Ping Guo
- School of Nursing, Hunan University of Tradtional Chinese Medicine, Changsha, Hunan, China
| | - Xiao-Yun Yu
- Department of Nursing, Chongqing City Hospital of Traditional Chinese Medicine, Chongqing, China
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9
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Pelusio C, Endres P, Neyra JA, Allegretti AS. Renal Replacement Therapy in Cirrhosis: A Contemporary Review. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:133-138. [PMID: 38649217 PMCID: PMC11103613 DOI: 10.1053/j.akdh.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/20/2023] [Accepted: 01/02/2024] [Indexed: 04/25/2024]
Abstract
Acute kidney injury is a common complication of decompensated cirrhosis, frequently requires hospitalization, and carries a high short-term mortality. This population experiences several characteristic types of acute kidney injury: hypovolemic-mediated (prerenal), ischemic/nephrotoxic-mediated (acute-tubular necrosis), and hepatorenal syndrome. Prerenal acute kidney injury is treated with volume resuscitation. Acute-tubular necrosis is treated by optimizing perfusion pressure and discontinuing the offending agent. Hepatorenal syndrome, a unique physiology of decreased effective arterial circulation leading to renal vasoconstriction and ultimately acute kidney injury, is treated with plasma expansion with albumin and splanchnic vasoconstrictors such as terlipressin or norepinephrine. Common acute stressors such as bleeding, infection, and volume depletion often contribute to multifactorial acute kidney injury. Even with optimal medical management, many clinicians are faced with the challenge of initiating renal replacement therapy in these patients. This article reviews the epidemiology, indications, and complex considerations of renal replacement therapy for acute kidney injury in decompensated cirrhosis.
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Affiliation(s)
- Caterina Pelusio
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy; Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Paul Endres
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA.
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10
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Allegretti AS, Patidar KR, Ma AT, Cullaro G. From past to present to future: Terlipressin and hepatorenal syndrome-acute kidney injury. Hepatology 2024:01515467-990000000-00741. [PMID: 38353565 PMCID: PMC11322426 DOI: 10.1097/hep.0000000000000790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/11/2023] [Indexed: 03/01/2024]
Abstract
Hepatorenal syndrome (HRS) is a rare and highly morbid form of kidney injury unique to patients with decompensated cirrhosis. HRS is a physiologic consequence of portal hypertension, leading to a functional kidney injury that can be reversed by restoring effective circulating volume and renal perfusion. While liver transplantation is the only definitive "cure" for HRS, medical management with vasoconstrictors and i.v. albumin is a cornerstone of supportive care. Terlipressin, a V1a receptor agonist that acts on the splanchnic circulation, has been used for many years outside the United States for the treatment of HRS. However, its recent Food and Drug Administration approval has generated new interest in this population, as a new base of prescribers now work to incorporate the drug into clinical practice. In this article, we review HRS pathophysiology and diagnostic criteria, the clinical use of terlipressin and alternative therapies, and identify areas of future research in the space of HRS and kidney injury in cirrhosis.
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Affiliation(s)
- Andrew S. Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kavish R. Patidar
- Section of Gastroenterology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston TX, USA
| | - Ann T. Ma
- Toronto Centre for Liver Disease, University Health Network, Toronto, Canada
| | - Giuseppe Cullaro
- Division of Gastroenterology, Department of Medicine, University of California-San Francisco, San Francisco CA, USA
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11
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Patel A, Walling A, Kanwal F, Serper M, Hernaez R, Sundaram V, Kaplan D, Taddei T, Mahmud N. Rates, patterns, and predictors of specialty palliative care consultation among patients with acute-on-chronic liver failure. JHEP Rep 2024; 6:100976. [PMID: 38274489 PMCID: PMC10808910 DOI: 10.1016/j.jhepr.2023.100976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 10/29/2023] [Accepted: 11/13/2023] [Indexed: 01/27/2024] Open
Abstract
Background & Aims There is growing acceptance that principles of palliative care should be integrated into the management of serious illnesses affecting the liver, such as acute-on-chronic liver failure (ACLF). However, rates, patterns, and predictors of specialty palliative care consultation among patients with ACLF have not been well-described. Methods We performed a retrospective cohort study of patients hospitalized with ACLF between 1/1/2008 and 12/31/2018 using the VOCAL cohort. Patients were followed until 6/2021. We used mixed-effects regression analyses to identify significant patient and facility factors associated with palliative care consultation. We examined timing of consultation, the influence of ACLF characteristics, and facility-level variation on receipt of palliative care consultation. Results We identified 21,987 patients hospitalized with ACLF, of whom 30.5% received specialty palliative care consultation. Higher ACLF grade (ACLF-2 [odds ratio (OR) 1.82, 95% CI 1.67-1.99], ACLF-3 [OR 3.06, 95% CI 2.76-3.40]), prior specialty palliative care consultation (OR 2.62, 95% CI 2.36-2.91), and hepatocellular carcinoma (OR 2.10, 95% CI 1.89-2.33) were associated with consultation. Consultation occurred latest and closest to the time of death for patients with ACLF-3 compared to ACLF-1 and ACLF-2. Significant facility-level variation in consultation persisted among patients with ACLF-3, despite adjusting for multiple patient and facility factors. Conclusion In this large cohort of hospitalized patients with ACLF, specialty palliative care consultation was rare, more common in patients with higher grade ACLF, and tended to occur closer to the time of death for the sickest patients. Greater attention should be placed on earlier integration of palliative care during acute hospitalizations in patients with ACLF. Impact and implications Though palliative care consultation is recommended for patients with acute-on-chronic liver failure, there is no data demonstrating how often this occurs during hospitalizations, on a population level. We found that consultation occurs in only 30.5% of patients and occurs later for patients with grade 3 acute-on-chronic liver failure. Our data should provoke clinicians to urgently consider quality improvement efforts to integrate palliative care into the management of these seriously ill patients.
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Affiliation(s)
- Arpan Patel
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- Department of Medicine, Greater Los Angeles VA Healthcare System, Los Angeles, CA, United States
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Anne Walling
- Department of Medicine, Greater Los Angeles VA Healthcare System, Los Angeles, CA, United States
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX, United States
- Department of Internal Medicine, Houston VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX, United States
- Department of Internal Medicine, Houston VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
| | - Vinay Sundaram
- Karsh Division of Gastroenterology and Hepatology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - David Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Tamar Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT, United States
- VA Connecticut Healthcare System, West Haven, CT, United States
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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12
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Batisti J, Jakab SS. Hospitalized patients with cirrhosis: Addressing gaps in care. Clin Liver Dis (Hoboken) 2024; 23:e0211. [PMID: 38961874 PMCID: PMC11221856 DOI: 10.1097/cld.0000000000000211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/15/2024] [Indexed: 07/05/2024] Open
Affiliation(s)
- Jennifer Batisti
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sofia S. Jakab
- Section of Digestive Diseases, Yale University School of Medicine, VA Connecticut Healthcare System, New Haven, Connecticut, USA
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13
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Shehadah A, Yu Naing L, Bapaye J, Malik S, Mohamed M, Khalid N, Munoz A, Jadhav N, Mushtaq A, Okolo P, Eskridge E. Early palliative care referral may improve end-of-life care in end-stage liver disease patients: A retrospective analysis from a non-transplant center. Am J Med Sci 2024; 367:35-40. [PMID: 37923293 DOI: 10.1016/j.amjms.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/22/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Patients with end-stage liver disease (ESLD) who are not transplant candidates often have a trajectory of rapid decline and death similar to patients with stage IV cancer. Palliative care (PC) services have been shown to be underutilized for such patients. Most studies examining the role of PC in ESLD have been done at transplant centers. Thus, determining the utilization and benefit of PC at a non-transplant tertiary center may help establish a standard of care in the management of patients with ESLD not eligible for transplant. METHODS We conducted a retrospective analysis of adult (>18 years) patients with ESLD admitted to Rochester Regional Health (RRH) system hospitals from 2012 to 2021. Patients were divided into groups based on the presence or absence of PC involvement. Baseline characteristics were recorded. The impact of PC was assessed by comparing the number of hospitalizations before and after the involvement of PC, comparing code status changes, health care proxy (HCP) assignments, Aspira catheter placements, and frequency of repeated paracentesis. RESULTS In our analysis of 576 patients, 41.1% (237 patients) received a PC consult (PC group), while 58.9% (339 patients) did not (no-PC group). Baseline characteristics were comparable. However, their mean number of admissions significantly decreased (15.66 vs. 3.49, p < 0.001) after PC involvement. Full code status was more prevalent in the no-PC group (67.8% vs. 18.6%, p < 0.001), while comfort care code status was more common in the PC group (59.9% vs. 20.6%, p < 0.001). Changes in code status were significantly higher in the PC group (77.6% vs. 29.2%, p < 0.001). The PC group had a significantly higher mortality rate (83.1% vs. 46.4%, p < 0.01). Patients in the PC group had a higher likelihood of having an assigned HCP (63.7% vs. 37.5%, p < 0.001). PC referral was associated with more frequent use of an Aspira catheter (5.9% vs. 0.9%, p < 0.001) and more frequent paracentesis (30.8% vs. 16.8%, p < 0.001). CONCLUSIONS In conclusion, our study provides compelling evidence of the diverse advantages of palliative care for patients with end-stage liver disease, including reduced admissions, improved goals of care, code status modifications, enhanced healthcare proxy assignments, and targeted interventions. These findings highlight the potential significance of early integration of palliative care in the disease trajectory to provide comprehensive, patient-centered care that addresses the unique needs and preferences of individuals with advanced liver disease.
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Affiliation(s)
- Ahmed Shehadah
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States.
| | - Le Yu Naing
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Jay Bapaye
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Sheza Malik
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Mohamed Mohamed
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Nida Khalid
- Department of Gastroenterology, Rochester General Hospital, Rochester, New York, United States
| | - Anisleidys Munoz
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Nagesh Jadhav
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Asim Mushtaq
- Department of Gastroenterology, Rochester General Hospital, Rochester, New York, United States
| | - Patrick Okolo
- Department of Gastroenterology, Rochester General Hospital, Rochester, New York, United States
| | - Etta Eskridge
- Department of Palliative Care, Rochester General Hospital, Rochester, New York, United States
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14
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Patidar KR, Belcher JM, Regner KR, St Hillien SA, Simonetto DA, Asrani SK, Neyra JA, Sharma P, Velez JCQ, Wadei H, Nadim MK, Chung RT, Seethapathy R, Parada XV, Ouyang T, Ufere NN, Robinson JE, McLean Diaz P, Wilechansky RM, Przybyszewski EM, Smith TN, Ali AA, Orman ES, Schulz P, Siddiqui SM, Shabbir R, Liu LJ, Cama-Olivares A, Flannery AH, Baker ML, Gunasekaran D, Aswine A, Issa R, Li J, Verma S, Chalmers D, Varghese V, Lam W, Mohamed M, Kovacic R, Gaddy A, Attieh RM, Cortes P, Semnani S, Wang L, Khemichian S, Allegretti AS. Incidence and outcomes of acute kidney injury including hepatorenal syndrome in hospitalized patients with cirrhosis in the US. J Hepatol 2023; 79:1408-1417. [PMID: 37517455 PMCID: PMC10807505 DOI: 10.1016/j.jhep.2023.07.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND & AIMS Acute kidney injury (AKI) in cirrhosis is common and associated with high morbidity, but the incidence rates of different etiologies of AKI are not well described in the US. We compared incidence rates, practice patterns, and outcomes across etiologies of AKI in cirrhosis. METHODS We performed a retrospective cohort study of 11 hospital networks, including consecutive adult patients admitted with AKI and cirrhosis in 2019. The etiology of AKI was adjudicated based on pre-specified clinical definitions (prerenal/hypovolemic AKI, hepatorenal syndrome [HRS-AKI], acute tubular necrosis [ATN], other). RESULTS A total of 2,063 patients were included (median age 62 [IQR 54-69] years, 38.3% female, median MELD-Na score 26 [19-31]). The most common etiology was prerenal AKI (44.3%), followed by ATN (30.4%) and HRS-AKI (12.1%); 6.0% had other AKI, and 7.2% could not be classified. In our cohort, 8.1% of patients received a liver transplant and 36.5% died by 90 days. The lowest rate of death was observed in patients with prerenal AKI (22.2%; p <0.001), while death rates were higher but not significantly different from each other in those with HRS-AKI and ATN (49.0% vs. 52.7%; p = 0.42). Using prerenal AKI as a reference, the adjusted subdistribution hazard ratio (sHR) for 90-day mortality was higher for HRS-AKI (sHR 2.78; 95% CI 2.18-3.54; p <0.001) and ATN (sHR 2.83; 95% CI 2.36-3.41; p <0.001). In adjusted analysis, higher AKI stage and lack of complete response to treatment were associated with an increased risk of 90-day mortality (p <0.001 for all). CONCLUSION AKI is a severe complication of cirrhosis. HRS-AKI is uncommon and is associated with similar outcomes to ATN. The etiology of AKI, AKI stage/severity, and non-response to treatment were associated with mortality. Further optimization of vasoconstrictors for HRS-AKI and supportive therapies for ATN are needed. IMPACT AND IMPLICATIONS Acute kidney injury (AKI) in cirrhosis carries high morbidity, and management is determined by the etiology of injury. However, a large and well-adjudicated multicenter database from US centers that uses updated AKI definitions is lacking. Our findings demonstrate that acute tubular necrosis and hepatorenal syndrome have similar outcomes (∼50% mortality at 90 days), though hepatorenal syndrome is uncommon (12% of all AKI cases). These findings represent practice patterns at US transplant/tertiary centers and can be used as a baseline, presenting the situation prior to the adoption of terlipressin in the US.
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Affiliation(s)
- Kavish R Patidar
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Justin M Belcher
- Section of Nephrology, Department of Internal Medicine, Yale University and VA Connecticut Healthcare, New Haven, CT, USA
| | - Kevin R Regner
- Division of Nephrology at the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Shelsea A St Hillien
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Transplant Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Pratima Sharma
- Department of Gastroenterology and Transplant Hepatology at University of Michigan Health, Ann Arbor, MI, USA
| | - Juan Carlos Q Velez
- Department of Nephrology at the Ochsner Medical Center, New Orleans, LA, USA
| | - Hani Wadei
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Raymond T Chung
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ritu Seethapathy
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Xavier Vela Parada
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Tianqi Ouyang
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nneka N Ufere
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jevon E Robinson
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Paige McLean Diaz
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Robert M Wilechansky
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Eric M Przybyszewski
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas N Smith
- Division of Gastroenterology and Transplant Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Arzina Aziz Ali
- Division of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | | | - Lucas J Liu
- Division of Biomedical Informatics, Department of Medicine and Department of Computer Science, University of Kentucky, Lexington, KY, USA
| | - Augusto Cama-Olivares
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alexander H Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Megan L Baker
- Section of Nephrology, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Deepthi Gunasekaran
- Section of Nephrology, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Adeline Aswine
- Department of Internal Medicine at University of Michigan Health, Ann Arbor, MI, USA
| | - Rafik Issa
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jay Li
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Shreya Verma
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Dustin Chalmers
- Department of Nephrology at the Ochsner Medical Center, New Orleans, LA, USA
| | - Vipin Varghese
- Department of Nephrology at the Ochsner Medical Center, New Orleans, LA, USA
| | - Walter Lam
- Department of Nephrology at the Ochsner Medical Center, New Orleans, LA, USA
| | - Muner Mohamed
- Department of Nephrology at the Ochsner Medical Center, New Orleans, LA, USA
| | - Rosemary Kovacic
- Department of Nephrology at the Ochsner Medical Center, New Orleans, LA, USA
| | - Anna Gaddy
- Division of Nephrology at the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rose Mary Attieh
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Pedro Cortes
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Sahar Semnani
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lin Wang
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Saro Khemichian
- Division of Gastrointestinal and Liver Disease, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
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15
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Singal AG, Llovet JM, Yarchoan M, Mehta N, Heimbach JK, Dawson LA, Jou JH, Kulik LM, Agopian VG, Marrero JA, Mendiratta-Lala M, Brown DB, Rilling WS, Goyal L, Wei AC, Taddei TH. AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma. Hepatology 2023; 78:1922-1965. [PMID: 37199193 PMCID: PMC10663390 DOI: 10.1097/hep.0000000000000466] [Citation(s) in RCA: 414] [Impact Index Per Article: 414.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/19/2023]
Affiliation(s)
- Amit G. Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Josep M. Llovet
- Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Mount Sinai School of Medicine, New York, New York, USA
- Translational Research in Hepatic Oncology, Liver Unit, August Pi i Sunyer Biomedical Research Institute, Hospital Clinic, University of Barcelona, Catalonia, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Catalonia, Spain
| | - Mark Yarchoan
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Neil Mehta
- University of California, San Francisco, San Francisco, California, USA
| | | | - Laura A. Dawson
- Radiation Medicine Program/University Health Network, Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Janice H. Jou
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Laura M. Kulik
- Northwestern Medical Faculty Foundation, Chicago, Illinois, USA
| | - Vatche G. Agopian
- The Dumont–University of California, Los Angeles, Transplant Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Jorge A. Marrero
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mishal Mendiratta-Lala
- Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Daniel B. Brown
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William S. Rilling
- Division of Interventional Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lipika Goyal
- Department of Medicine, Stanford School of Medicine, Palo Alto, California, USA
| | - Alice C. Wei
- Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Tamar H. Taddei
- Department of Medicine (Digestive Diseases), Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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16
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Miller K, Barman P, Kappus M. Palliative care and end of life care in decompensated cirrhosis. Clin Liver Dis (Hoboken) 2023; 22:10-13. [PMID: 37521186 PMCID: PMC10378809 DOI: 10.1097/cld.0000000000000044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/09/2023] [Indexed: 08/01/2023] Open
Affiliation(s)
- Kaela Miller
- Department of Internal Medicine, Duke University, Durham, North Carolina, USA
| | - Pranab Barman
- Division of Gastroenterology and Hepatology, University of California San Diego; San Diego, California, USA
| | - Matthew Kappus
- Division of Gastroenterology and Hepatology, Duke University, Durham, North Carolina, USA
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17
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When to Stop Screening-Liver Cancer. Am J Gastroenterol 2023; 118:427-428. [PMID: 36563304 DOI: 10.14309/ajg.0000000000002120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/12/2022] [Indexed: 12/25/2022]
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18
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Walling AM, Ast K, Harrison JM, Dy SM, Ersek M, Hanson LC, Kamal AH, Ritchie CS, Teno JM, Rotella JD, Periyakoil VS, Ahluwalia SC. Patient-Reported Quality Measures for Palliative Care: The Time is now. J Pain Symptom Manage 2023; 65:87-100. [PMID: 36395918 DOI: 10.1016/j.jpainsymman.2022.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022]
Abstract
CONTEXT While progress has been made in the ability to measure the quality of hospice and specialty palliative care, there are notable gaps. A recent analysis conducted by Center for Medicare and Medicaid Services (CMS) revealed a paucity of patient-reported measures, particularly in palliative care domains such as symptom management and communication. OBJECTIVES The research team, consisting of quality measure and survey developers, psychometricians, and palliative care clinicians, used established state-of-the art methods for developing and testing patient-reported measures. METHODS We applied a patient-centered, patient-engaged approach throughout the development and testing process. This sequential process included 1) an information gathering phase; 2) a pre-testing phase; 3) a testing phase; and 4) an endorsement phase. RESULTS To fill quality measure gaps identified during the information gathering phase, we selected two draft measures ("Feeling Heard and Understood" and "Receiving Desired Help for Pain") for testing with patients receiving palliative care in clinic-based settings. In the pre-testing phase, we used an iterative process of cognitive interviews to refine draft items and corresponding response options for the proposed measures. The alpha pilot test supported establishment of protocols for the national beta field test. Measures met conventional criteria for reliability, had strong face and construct validity, and there was diversity in program level scores. The measures received National Quality Forum (NQF) endorsement. CONCLUSION These measures highlight the key role of patient voices in palliative care and fill a much-needed gap for patient-reported experience measures in our field.
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Affiliation(s)
- Anne M Walling
- Department of Medicine (A.W.), University of California, Los Angeles, California; VA Greater Los Angeles Health System (A.W.), Los Angeles, California; RAND Health Care (A.W., J.H., S.A.), Santa Monica, California.
| | - Katherine Ast
- American Academy of Hospice and Palliative Medicine (K.A.,J.R.), Chicago, Illinois
| | | | - Sydney M Dy
- Department of Health Policy and Management (S.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mary Ersek
- Department of Veterans Affairs (M.E.), Philadelphia, Pennsylvania; University of Pennsylvania Schools of Nursing and Medicine (M.E.), Philadelphia, Pennsylvania
| | - Laura C Hanson
- Division of Geriatric Medicine and Palliative Care Program (L.H.), University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Arif H Kamal
- Duke University School of Medicine (A.K.), Durham, North Carolina
| | - Christine S Ritchie
- The Mongan Institute and the Division of Palliative Care and Geriatric Medicine ( C.R.), Massachusetts General Hospital, Boston, Massachusetts
| | - Joan M Teno
- Oregon Health and Science University School of Medicine (J.T.), Portland, Oregon
| | - Joseph D Rotella
- American Academy of Hospice and Palliative Medicine (K.A.,J.R.), Chicago, Illinois
| | - Vyjeyanthi S Periyakoil
- Stanford University School of Medicine (V.P.),Stanford, California; VA Palo Alto Health Care System (V.P.), Livemore, California, USA
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19
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Jaffe A, Taddei TH, Giannini EG, Ilagan-Ying YC, Colombo M, Strazzabosco M. Holistic management of hepatocellular carcinoma: The hepatologist's comprehensive playbook. Liver Int 2022; 42:2607-2619. [PMID: 36161463 PMCID: PMC10878125 DOI: 10.1111/liv.15432] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/26/2022] [Accepted: 09/21/2022] [Indexed: 12/12/2022]
Abstract
Hepatocellular carcinoma (HCC) is a common complication in patients with chronic liver disease and leads to significant morbidity and mortality. Liver disease and liver cancer are preventable by mitigating and managing common risk factors, including chronic hepatitis B and C infection, alcohol use, diabetes, obesity and other components of the metabolic syndrome. The management of patients with HCC requires treatment of the malignancy and adequate control of the underlying liver disease, as preserving liver function is critical for successful cancer treatment and may have a relevant prognostic role independent of HCC management. Hepatologists are the ideal providers to guide the care of patients with HCC as they are trained to identify patients at risk, apply appropriate surveillance strategies, assess and improve residual liver function, evaluate candidacy for transplant, provide longitudinal care to optimize and preserve liver function during and after HCC treatment, survey for cancer recurrence and manage its risk factors, and prevent and treat decompensating events. We highlight the need for a team-based holistic approach to the patient with liver disease and HCC and identify necessary gaps in current care and knowledge.
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Affiliation(s)
- Ariel Jaffe
- Liver Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Smilow Cancer Hospital and Liver Cancer Program, New Haven, CT, USA
| | - Tamar H. Taddei
- Liver Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Edoardo G. Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Ysabel C. Ilagan-Ying
- Liver Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | - Mario Strazzabosco
- Liver Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Smilow Cancer Hospital and Liver Cancer Program, New Haven, CT, USA
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20
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Arney J, Gray C, Walling AM, Clark JA, Smith D, Melcher J, Asch S, Kanwal F, Naik AD. Two mental models of integrated care for advanced liver disease: qualitative study of multidisciplinary health professionals. BMJ Open 2022; 12:e062836. [PMID: 36691142 PMCID: PMC9445787 DOI: 10.1136/bmjopen-2022-062836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/16/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES The purpose of this paper is to present two divergent mental models of integrated advanced liver disease (AdvLD) care among 26 providers who treat patients with AdvLD. SETTING 3 geographically dispersed United States Veterans Health Administration health systems. PARTICIPANTS 26 professionals (20 women and 6 men) participated, including 9 (34.6%) gastroenterology, hepatology, and transplant physicians, 2 (7.7%) physician assistants, 7 (27%) nurses and nurse practitioners, 3 (11.5%) social workers and psychologists, 4 (15.4%) palliative care providers and 1 (3.8%) pharmacist. MAIN OUTCOME MEASURES We conducted qualitative in-depth interviews of providers caring for patients with AdvLD. We used framework analysis to identify two divergent mental models of integrated AdvLD care. These models vary in timing of initiating various constituents of care, philosophy of integration, and supports and resources needed to achieve each model. RESULTS Clinicians described integrated care as an approach that incorporates elements of curative care, symptom and supportive care, advance care planning and end-of-life services from a multidisciplinary team. Analysis revealed two mental models that varied in how and when these constituents are delivered. One mental model involves sequential transitions between constituents of care, and the second mental model involves synchronous application of the various constituents. Participants described elements of teamwork and coordination supports necessary to achieve integrated AdvLD care. Many discussed the importance of having a multidisciplinary team integrating supportive care, symptom management and palliative care with liver disease care. CONCLUSIONS Health professionals agree on the constituents of integrated AdvLD care but describe two competing mental models of how these constituents are integrated. Health systems can promote integrated care by assembling multidisciplinary teams, and providing teamwork and coordination supports, and training that facilitates patient-centred AdvLD care.
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Affiliation(s)
- Jennifer Arney
- Department of Sociology, University of Houston Clear Lake, Houston, Texas, USA
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Caroline Gray
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Anne M Walling
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California at Los Angeles, Los Angeles, California, USA
| | - Jack A Clark
- Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Donna Smith
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
| | - Jennifer Melcher
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
| | - Steven Asch
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Division of General Medical Disciplines, Stanford School of Medicine, Stanford, California, USA
| | - Fasiha Kanwal
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Aanand D Naik
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
- University of Texas Health Consortium on Aging, University of Texas Health Science Center, Houston, Texas, USA
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston, Texas, USA
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21
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Rogal SS, Hansen L, Patel A, Ufere NN, Verma M, Woodrell CD, Kanwal F. AASLD Practice Guidance: Palliative care and symptom-based management in decompensated cirrhosis. Hepatology 2022; 76:819-853. [PMID: 35103995 PMCID: PMC9942270 DOI: 10.1002/hep.32378] [Citation(s) in RCA: 77] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Shari S. Rogal
- Departments of Medicine and Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare Center, Pittsburgh, Pennsylvania, USA
| | - Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland, Oregon, USA
| | - Arpan Patel
- Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Nneka N. Ufere
- Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Christopher D. Woodrell
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Fasiha Kanwal
- Sections of Gastroenterology and Hepatology and Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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22
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Shaw J, Beyers L, Bajaj JS. Inadequate practices for hepatic encephalopathy management in the inpatient setting. J Hosp Med 2022; 17 Suppl 1:S8-S16. [PMID: 35972037 PMCID: PMC9542542 DOI: 10.1002/jhm.12897] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/23/2022] [Accepted: 05/27/2022] [Indexed: 11/18/2022]
Abstract
Hepatic encephalopathy (HE) is an important complication of decompensated liver disease. Hospital admission for episodes of HE are very common, with these patients being managed by the hospitalists. These admissions are costly and burdensome to the health-care system. Diagnosis of HE at times is not straightforward, particularly in patients who are altered and unable to provide any history. Precipitants leading to episodes of HE, should be actively sought and effectively tackled along with the overall management. This mandates timely diagnostics, appropriate initiation of pharmacological treatment, and supportive care. Infections are the most important precipitants leading to HE and should be aggressively managed. Lactulose is the front-line medication for primary treatment of HE episodes and for prevention of subsequent recurrence. However, careful titration in the hospital setting along with the appropriate route of administration should be established and supervised by the hospitalist. Rifaximin has established its role as an add-on medication, in those cases where lactulose alone is not working. Overall effective management of HE calls for attention to guideline-directed nutritional requirements, functional assessment, medication reconciliation, patient education/counseling, and proper discharge planning. This will potentially help to reduce readmissions, which are all too common for HE patients. Early specialty consultation may be warranted in certain conditions. Numerous challenges exist to optimal care of hospitalized OHE patients. However, hospitalists if equipped with knowledge about a systematic approach to taking care of these frail patients are in an ideal position to ensure good inpatient and transition of care outcomes.
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Affiliation(s)
- Jawaid Shaw
- Department of Internal Medicine, Division of Hospital MedicineVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Lisa Beyers
- Department of Internal Medicine, Strong Memorial HospitalUniversity of RochesterRochesterNew YorkUSA
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology and NutritionVirginia Commonwealth University and Central Virginia Veterans Healthcare SystemRichmondVirginiaUSA
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23
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Whitsett MP, Ufere NN, Patel A, Shea JA, Jones CA, Fix OK, Serper M. Palliative care experience and perceived gaps in training among transplant hepatology fellows: A national survey. Hepatol Commun 2022; 6:1680-1688. [PMID: 35411683 PMCID: PMC9234628 DOI: 10.1002/hep4.1939] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/25/2022] [Accepted: 02/17/2022] [Indexed: 11/20/2022] Open
Abstract
Despite the likely benefits of palliative care (PC) for patients with cirrhosis, physician experiences and perspectives about best practices are variable. We aimed to assess PC experience and gaps in training among transplant hepatology fellows. We conducted a national survey of all transplant hepatology fellows enrolled in accredited fellowship programs during the 2020-2021 academic year. We assessed the frequency of PC provision and comfort with physical and psychological symptom management, psychosocial care, communication skills, advance care planning, and end-of-life care. A total of 45 of 56 (79%) of transplant hepatology fellows responded to the survey; 50% (n = 22) were female. Most trained at centers performing over 100 transplants per year (67%, n = 29) distributed evenly across geographic regions. Most fellows (69%, n = 31) had a PC or hospice care rotation during residency, and 42% (n = 19) of fellows received education in PC during transplant hepatology fellowship. Fellows reported feeling moderately to very comfortable with communication skills such as breaking bad news (93%, n = 41) and leading family meetings (75%, n = 33), but nearly one-third (30%, n = 13) reported feeling not very or not at all comfortable assessing and managing anxiety and depression (30%, n = 13) and spiritual distress (34%, n = 15). Nearly one-quarter (22%, n = 10) had never discussed or documented advance care plans during fellowship. Fellows wished to receive future instruction on the assessment and management of physical symptoms (68%, n = 30) and anxiety and depression (64%, n = 28). Conclusion: Our survey highlights gaps in PC experience and education during transplant hepatology fellowship, lack of comfort in managing psychological distress and advance care planning, and desire to improve skills, particularly in symptom management. Future studies should investigate how to enhance transplant hepatology competencies in these PC domains and whether this impacts clinical care, advance care planning, or patient experience.
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Affiliation(s)
- Maureen P Whitsett
- Division of Gastroenterology and HepatologyCleveland ClinicClevelandOhioUSA
| | - Nneka N Ufere
- Liver CenterGastrointestinal UnitMassachusetts General HospitalBostonMassachusettsUSA
| | - Arpan Patel
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of MedicineDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA.,Veterans Affairs Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
| | - Judy A Shea
- Division of General Internal MedicineDepartment of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Christopher A Jones
- Department of Internal MedicineDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Oren K Fix
- Division of Gastroenterology and HepatologyUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Marina Serper
- Division of Gastroenterology and HepatologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA.,Corporal Michael J. Crescenz VA Medical CenterPhiladelphiaPennsylvaniaUSA.,Leonard Davis InstituteUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
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24
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Ufere NN, Patzer RE, Kavalieratos D, Louissaint J, Kaplan A, Cross SH. Rural-Urban Disparities in Mortality From Cirrhosis in the United States From 1999 to 2019. Am J Gastroenterol 2022; 117:1162-1165. [PMID: 35213405 DOI: 10.14309/ajg.0000000000001712] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 02/23/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION We examined trends in rural-urban cirrhosis mortality disparities in the United States from decedents aged 25 years and older from 1999 to 2019. METHODS We calculated cirrhosis age-adjusted mortality rates across 3 population categories: large metropolitan (≥1 million), medium/small metropolitan (50,000-999,999), and rural (<50,000) areas using the US Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research database. RESULTS We found an almost 20-fold increase in the absolute difference in cirrhosis age-adjusted mortality rates between rural and large metropolitan areas between 1999 and 2019. DISCUSSION Future research is needed to investigate reasons for this widening rural-urban disparity to improve rural cirrhosis care.
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Affiliation(s)
- Nneka N Ufere
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rachel E Patzer
- Emory Health Services Research Center, Departments of Medicine and Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jeremy Louissaint
- Center for Liver Disease and Transplantation, Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Alyson Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Sarah H Cross
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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25
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Patel K, Tandon P, Hernaez R. Palliative Care in the Patient With Acute-on-Chronic Liver Failure. Clin Liver Dis (Hoboken) 2022; 19:198-202. [PMID: 35662869 PMCID: PMC9135150 DOI: 10.1002/cld.1201] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Content available: Author Interview and Audio Recording.
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Affiliation(s)
- Kinjal Patel
- Liver UnitDivision of GastroenterologyDepartment of MedicineUniversity of AlbertaEdmontonABCanada
| | - Puneeta Tandon
- Liver UnitDivision of GastroenterologyDepartment of MedicineUniversity of AlbertaEdmontonABCanada
| | - Ruben Hernaez
- Section of Gastroenterology. Michael E. DeBakey Veterans Affairs Medical CenterHoustonTX,Center for Innovations in Quality, Effectiveness and SafetyMichael E. DeBakey Veterans Affairs Medical CenterHoustonTX,Section of Gastroenterology and HepatologyDepartment of MedicineBaylor College of MedicineHoustonTX
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26
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Berry P, Kotha S. Improving end of life care in liver disease. J Hepatol 2022; 76:1225-1226. [PMID: 35063299 DOI: 10.1016/j.jhep.2021.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/20/2021] [Accepted: 10/04/2021] [Indexed: 12/04/2022]
Affiliation(s)
- Philip Berry
- Department of Gastroenterology, Guy's and St Thomas' Foundation Trust, London, United Kingdom
| | - Sreelakshmi Kotha
- Department of Gastroenterology, Guy's and St Thomas' Foundation Trust, London, United Kingdom.
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27
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Tombazzi CR, Howe CF, Slaughter JC, Obstein KL. Rate of and Factors Associated with Palliative Care Referral among Patients Declined for Liver Transplantation. J Palliat Med 2022; 25:1404-1408. [PMID: 35333610 DOI: 10.1089/jpm.2021.0403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: End-stage liver disease (ESLD) is associated with high morbidity and mortality, with liver transplantation as the only existing cure. Despite reduced quality of life and limited life expectancy, referral to palliative care (PC) rarely occurs. Moreover, there is scarcity of data on the appropriate timing and type of PC intervention needed. Aim: To evaluate PC utilization and documentation in ESLD patients declined or delisted for transplant at a tertiary care medical center with a large liver transplantation program. Methods: We performed a retrospective cohort study of all patients discussed in Liver Transplant Committee (LTC) at our academic medical center between August 2018 and May 2020 in the United States. Patients declined or delisted for liver transplantation were included. Baseline demographics, model for end-stage liver disease (MELD) score, decompensation events, and reason for transplant ineligibility were recorded. The primary outcome was PC referral. Secondary outcomes included survival from LTC decision, time from LTC decision to PC referral, and code status in relation to PC referral. Results: Of 769 patients discussed at LTC, 135 were declined for transplantation. Thirty-seven (27%) received referral to PC. When adjusting for body mass index and age, MELD score of 21-30 had odds ratio (OR) of 4.5 (95% confidence interval [CI]: 1.7-12.3) and MELD score >30 had OR of 12.8 (95% CI: 3.9-47.7) for PC referral when compared with MELD score <20. When adjusting for MELD score, presence of ascites had OR of 4.6 (95% CI: 1.1-19.1) and presence of multiple complications had OR of 2.2 (95% CI: 2.2-3.8). Conclusions: Only 37 (27%) patients delisted or declined for liver transplantation were referred to PC. MELD score and degree of decompensation were important factors associated with referral. Continued exploration of these data could help guide future studies and help determine timing and criteria for PC referral.
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Affiliation(s)
- Claudio Roberto Tombazzi
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Catherine Filley Howe
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James Chris Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Keith L Obstein
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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28
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Hui Y, Li N, Yu Z, Li C, Wang X, Li Y, Sun M, Yang W, Guo G, Fan X, Lin L, Cui B, Chen X, Wang B, Zhang J, Sun C. Health-Related Quality of Life and Its Contributors According to a Preference-Based Generic Instrument in Cirrhosis. Hepatol Commun 2022; 6:610-620. [PMID: 34558226 PMCID: PMC8870013 DOI: 10.1002/hep4.1827] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/25/2021] [Accepted: 09/05/2021] [Indexed: 01/13/2023] Open
Abstract
It is essential to determine contributors around impairment in health-related quality of life (HRQoL) in patients with cirrhosis aiming at improving health care and therapeutic strategy. Studies simultaneously incorporating disease severity based on biochemical parameters and other physical/psychological effects (i.e., sleep disturbance and frailty) are heterogeneous and the subject of the present study. We analyzed and compared HRQoL, using the EuroQol Group 5 Dimension (EQ-5D) questionnaire and the utility index retrieved, in patients with cirrhosis and across groups stratified by sleep disturbance or frailty phenotype. Sleep disturbance and frailty were determined by the Pittsburgh Sleep Quality Index (PSQI) and Frailty Index, respectively. Multiple linear regression was implemented to clarify contributors of poor HRQoL. In this cohort of 227 patients with mean age of 61.7 years and 47.2% male, more than half of the study population represented impairment in HRQoL in at least one domain, according to EQ-5D. Furthermore, sleep disturbance and frailty have proved to be independently associated with poor HRQoL in two separate regression models, whereas conventional scoring systems such as Child-Pugh classification and Model for End-Stage Liver Disease are not closely relevant. Intriguingly, not all health domains within EQ-5D correlated well with PSQI and Frailty Index, with the exception of usual activities. Pain and anxiety/depression were the most frequently affected HRQoL domains even in patients without sleep disturbance or frailty. Conclusion: Impaired HRQoL is prevalent in patients with decompensated cirrhosis. Sleep disturbance and frailty are independently associated with poor HRQoL. It is imperative to timely intervene with these symptoms and deliver tailored health care.
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Affiliation(s)
- Yangyang Hui
- Department of Gastroenterology and HepatologyTianjin Medical University General HospitalTianjinChina.,Tianjin Institute of Digestive DiseaseTianjin Medical University General HospitalTianjinChina
| | - Nan Li
- Department of Gastroenterology and HepatologyTianjin Medical University General HospitalTianjinChina
| | - Zihan Yu
- Department of Gastroenterology and HepatologyTianjin Medical University General HospitalTianjinChina.,Tianjin Institute of Digestive DiseaseTianjin Medical University General HospitalTianjinChina
| | - Chaoqun Li
- Department of Gastroenterology and HepatologyTianjin Medical University General HospitalTianjinChina.,Department of Internal MedicineTianjin Hexi HospitalTianjinChina
| | - Xiaoyu Wang
- Department of Gastroenterology and HepatologyTianjin Medical University General HospitalTianjinChina.,Tianjin Institute of Digestive DiseaseTianjin Medical University General HospitalTianjinChina
| | - Yifan Li
- Department of Gastroenterology and HepatologyTianjin Medical University General HospitalTianjinChina.,Tianjin Institute of Digestive DiseaseTianjin Medical University General HospitalTianjinChina
| | - Mingyu Sun
- Department of Gastroenterology and HepatologyTianjin Medical University General HospitalTianjinChina.,Tianjin Institute of Digestive DiseaseTianjin Medical University General HospitalTianjinChina
| | - Wanting Yang
- Department of Gastroenterology and HepatologyTianjin Medical University General HospitalTianjinChina.,Tianjin Institute of Digestive DiseaseTianjin Medical University General HospitalTianjinChina
| | - Gaoyue Guo
- Department of Gastroenterology and HepatologyTianjin Medical University General HospitalTianjinChina.,Tianjin Institute of Digestive DiseaseTianjin Medical University General HospitalTianjinChina
| | - Xiaofei Fan
- Department of Gastroenterology and HepatologyTianjin Medical University General HospitalTianjinChina.,Tianjin Institute of Digestive DiseaseTianjin Medical University General HospitalTianjinChina
| | - Lin Lin
- Department of GastroenterologyTianjin Medical University General Hospital Airport HospitalTianjin Airport Economic AreaTianjinChina
| | - Binxin Cui
- Department of GastroenterologyTianjin Medical University General Hospital Airport HospitalTianjin Airport Economic AreaTianjinChina
| | - Xin Chen
- Department of Gastroenterology and HepatologyTianjin Medical University General HospitalTianjinChina.,Tianjin Institute of Digestive DiseaseTianjin Medical University General HospitalTianjinChina
| | - Bangmao Wang
- Department of Gastroenterology and HepatologyTianjin Medical University General HospitalTianjinChina.,Tianjin Institute of Digestive DiseaseTianjin Medical University General HospitalTianjinChina
| | - Jie Zhang
- Department of Gastroenterology and HepatologyTianjin Medical University General HospitalTianjinChina.,Tianjin Institute of Digestive DiseaseTianjin Medical University General HospitalTianjinChina
| | - Chao Sun
- Department of Gastroenterology and HepatologyTianjin Medical University General HospitalTianjinChina.,Tianjin Institute of Digestive DiseaseTianjin Medical University General HospitalTianjinChina.,Department of GastroenterologyTianjin Medical University General Hospital Airport HospitalTianjin Airport Economic AreaTianjinChina
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29
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Rivera‐Esteban J, Armandi A, Augustin S, Bugianesi E. Outcomes and potential surrogate markers for future clinical trials of non-alcoholic steatohepatitis cirrhosis. Liver Int 2021; 41:1999-2008. [PMID: 34242466 PMCID: PMC8457215 DOI: 10.1111/liv.15013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/18/2021] [Accepted: 07/05/2021] [Indexed: 12/13/2022]
Abstract
Non-alcoholic steatohepatitis has emerged as a major public health problem, and the burden of non-alcoholic steatohepatitis cirrhosis is projected to increase by 64%-156% by 2030. The threat is aggravated by the fact that are currently no approved drugs for the treatment of non-alcoholic steatohepatitis. In this paper, we review the main challenges to drug development in patients with non-alcoholic steatohepatitis cirrhosis, and describe the opportunities brought by the advances in the understanding of the clinical and pathophysiological nuances of cirrhosis. The design of therapeutic regimens for non-alcoholic steatohepatitis cirrhosis will vary according to the specific cirrhosis substage (compensated vs decompensated), and the specific mechanistic basis of therapy, targeted either at improving aetiology-specific pathways and/or at more general aetiology-agnostic processes. The understanding of the probabilistic expectations for the whole range of potential outcomes, rooted at different mechanistic drivers at each specific substage, will be essential in order to choose adequate estimands and therapeutic strategies for clinical trials and individual patients with non-alcoholic steatohepatitis cirrhosis. Finally, we provide a summary of the main pitfalls and uncertainties in the design of clinical trials for non-alcoholic steatohepatitis cirrhosis and discuss potential biomarkers for use in trials and practice for these patients.
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Affiliation(s)
- Jesús Rivera‐Esteban
- Liver UnitDepartment of Internal MedicineVall d’Hebron Hospital UniversitariVall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital CampusBarcelonaSpain,Universitat Autònoma de BarcelonaBellaterraSpain
| | - Angelo Armandi
- Department of Medical SciencesDivision of Gastroenterology and HepatologyA.O. Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | - Salvador Augustin
- Liver UnitDepartment of Internal MedicineVall d’Hebron Hospital UniversitariVall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital CampusBarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)Instituto de Salud Carlos IIIMadridSpain
| | - Elisabetta Bugianesi
- Department of Medical SciencesDivision of Gastroenterology and HepatologyA.O. Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
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30
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Ufere NN. Advance Care Planning and Goals of Care Discussions in Advanced Liver Disease. CURRENT HEPATOLOGY REPORTS 2021; 20:77-84. [PMID: 35083111 PMCID: PMC8788995 DOI: 10.1007/s11901-021-00565-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 06/14/2023]
Abstract
PURPOSE OF REVIEW Advance care planning (ACP) has been shown to improve multiple outcomes in patients with serious illnesses; however, patients with advanced liver disease, or cirrhosis, rarely receive timely ACP. The purpose of this review is to evaluate the current state of ACP for patients with advanced liver disease and to provide practical guidance for integrating early ACP into routine outpatient hepatology care. RECENT FINDINGS Due to multiple patient-, physician-, and systems-level barriers, patients with advanced liver disease have low rates of timely ACP engagement. Early identification and preparation of a surrogate decision-maker, enhancing clinician ACP communication skills, use of patient-centered educational tools, optimizing outpatient processes for ACP documentation, and early referral to specialty palliative care may help to improve current deficits in ACP for this population. SUMMARY Provision of early ACP to patients with advanced liver disease may better ensure that patients receive medical care that is consistent with their goals and values.
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Affiliation(s)
- Nneka N. Ufere
- Liver Center, Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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31
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Biggins SW, Angeli P, Garcia-Tsao G, Ginès P, Ling SC, Nadim MK, Wong F, Kim WR. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 74:1014-1048. [PMID: 33942342 DOI: 10.1002/hep.31884] [Citation(s) in RCA: 359] [Impact Index Per Article: 119.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Scott W Biggins
- Division of Gastroenterology and Hepatology, and Center for Liver Investigation Fostering discovEryUniversity of WashingtonSeattleWA
| | - Paulo Angeli
- Unit of Hepatic Emergencies and Liver TransplantationDepartment of MedicineDIMEDUniversity of PadovaPaduaItaly
| | - Guadalupe Garcia-Tsao
- Department of Internal MedicineSection of Digestive DiseasesYale UniversityNew HavenCT.,VA-CT Healthcare SystemWest HavenCT
| | - Pere Ginès
- Liver Unit, Hospital Clinic, and Institut d'Investigacions Biomèdiques August Pi i SunyerUniversity of BarcelonaBarcelonaSpain.,Centro de Investigación Biomèdica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)MadridSpain
| | - Simon C Ling
- The Hospital for Sick Children, Division of Gastroenterology, Hepatology and Nutrition, and Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Mitra K Nadim
- Division of NephrologyUniversity of Southern CaliforniaLos AngelesCA
| | - Florence Wong
- Division of Gastroenterology and HepatologyUniversity Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - W Ray Kim
- Division of Gastroenterology and HepatologyStanford UniversityPalo AltoCA
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Orman ES, Johnson AW, Ghabril M, Sachs GA. Hospice care for end stage liver disease in the United States. Expert Rev Gastroenterol Hepatol 2021; 15:797-809. [PMID: 33599185 PMCID: PMC8282639 DOI: 10.1080/17474124.2021.1892487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Patients with end-stage liver disease (ESLD) have impaired physical, psychological, and social functions, which can diminish patient quality of life, burden family caregivers, and increase health-care utilization. For those with a life expectancy of less than six months, these impairments and their downstream effects can be addressed effectively through high-quality hospice care, delivered by multidisciplinary teams and focused on the physical, emotional, social, and spiritual wellbeing of patients and caregivers, with a goal of improving quality of life. AREAS COVERED In this review, we examine the evidence supporting hospice for ESLD, we compare this evidence to that supporting hospice more broadly, and we identify potential criteria that may be useful in determining hospice appropriateness. EXPERT OPINION Despite the potential for hospice to improve care for those at the end of life, it is underutilized for patients with ESLD. Increasing the appropriate utilization of hospice for ESLD requires a better understanding of patient eligibility, which can be based on predictors of high short-term mortality and liver transplant ineligibility. Such hospice criteria should be data-driven and should accommodate the uncertainty faced by patients and physicians.
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Affiliation(s)
- Eric S. Orman
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine,Corresponding author: Eric S. Orman, Address: Division of Gastroenterology & Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202,
| | - Amy W. Johnson
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine
| | - Marwan Ghabril
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine
| | - Greg A. Sachs
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine,Indiana University Center for Aging Research, Regenstrief Institute, Inc
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